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Pain in the chest after cycling - Online Doctor Chats

Date : 21-Feb-2012
User rating for this question
Very Good Posted in: Lung and Chest disorders
Answered by

General & Family Physician
Practicing since : 2004
Answered : 1776 Questions
User :   I am 51 y/o male in generally good health. I ride a bicycle for exercise, and am reasonably fit. Each Sunday my wife and I ride 60-70 miles, plus additional exercise during the week. This morning, after about 2 hours of riding (half-way through the ride), I started feeling slight chest pain/difficulty breathing. It gradually got a bit worse through the rest of the ride, total of about 3 more hours of riding. I did not go to hospital because I don't believe cardiac infarction is a likely explanation. I had EKG not long ago, and blood pressure and EKG were fine. Cholesterol 170 and triglycerides low. Two years ago I was diagnosed with lone atrial fibrillation (paroxysmal AF); it is controlled without meds by maintaining mild exercise and some magnesium supplementation. At time of diagnosis, complete cardiac workup with echo cardiogram, nuclear stress test, and found to be in excellent cardiac health except for the AF issue. Many years ago I was diagnosed via endoscopy to have 15% hiatal hernia.
The pain is most acute when I breathe, and it is centered in my chest, i.e., located under my sternum mostly near the bottom, though I also feel very slight discomfort at the very top of the sternum. The pain doesn't feel like it is on the outer surface of the sternum, but something deeper inside. It is almost as if something underneath is hitting the xyphoid process and causing pain.
I rode bicycle 18 miles on Friday with no hint of this, and swam 1000 meters yesterday with no hint of it either. It only developed after about 2 hours of riding today (and bear in mind that this is completely normal for us--we ride 4-6 hours every Sunday for past 3 years, and a month ago completed a 430 mile ride over the course of a week, so this level of riding is not unusual).
I showered and rested after our ride today but 3 hours later the pain is only slightly reduced.
User :   The pain is worst if I lie on my stomach, especially as I am letting myself down into that position and my chest is somewhat hyperextended. Coughing is not painful; breathing deeply is.
I hypothesized that worst case scenario would be either cardio infarction, pneumothrombosis (from the LAF perhaps), or pneumothorax. As noted above, I really doubt the cardio since my heart has been tested and found to be in good condition quite recently. The symptoms/location of pain don't seem to line up either. I suppose the pulmonary problems could be responsible, but this is where I need help. Do the symptoms line up at all?
A condition I've read about online is costochondritis. This seems to match in many ways, and having had inflammation on the side of my rib cage many years ago I know how painful it can be, especially when breathing or laughing (in that case). In the event that it might be this, I've taken 200 mg Ibuprofen and may take more as the day goes on if there is not improvement.
I really don't want to go to the emergency room because (a) I hate spending hours and hours there; (b) costs lots of money; (c) I don't believe this is a serious condition (at least I don't think so yet). Can you help me? I'd like to know if costochondritis could develop in the course of a relatively short time, and if the position of riding a bicycle (hunched forward over a road bike) could realistically be expected to trigger it, even in someone who has ridden thousands of miles in the past year? I'd also like to know if it could be related to hiatal hernia and how to tell. And of course, what I really want is your professional opinion on what is/is not likely and what action I should take if any.
Sorry for the long description. Hope it provides the background information you need. And please don't let me speculations prejudice you. I want your professional
User :   opinion/judgment. Thanks.                                             
Doctor :   Hi
Doctor :   kindly give me some time to read your post , so that i can help you well
User :   sure...
Doctor :   Yes
Doctor :   quite a good description
User :   your thoughts?
Doctor :   Did you this time get any x ray / ecg / an repeat endoscopy ?
User :   no; as mentioned, this happened today and I haven't sought emergency room care.
User :   But I should also point out that I wear an exercise heart monitor and had very normal heartrate throughout.
Doctor :   good,
User :   I think my questions are especially focused on the nature of its development--why did it develop now, and after 2 hours of riding, and somewhat gradually (over the course of about an hour)
Doctor :   but after going through your history
Doctor :   i think the more probable cause could be from your stomach
User :   if that were true, it should disappear in a few hours of fasting, right?
User :   That is something easy enough to try if so.
Doctor :   Could not be always, since you said you had mild hiatus hernia fasting will not help
User :   The diagnosis was probably 15 years ago and I haven't noticed any particular problems with it. Why would it start causing pain today, and in the manner described?
User :   (though must confess I did eat a spicy Thai lunch yesterday, if that is a factor!)
Doctor :   hiatal hernia is known to present without warning
User :   Interesting
Doctor :   may be , since spicy
User :   My GI doc who made the diagnosis said at the time spicy is not a problem so I've not limited my intake. He is Bangladeshi so probably can't live without spice. I would find it hard too!
User :   So if it is the hiatal hernia, the answer is smaller meals and try to lose some weight, right?
User :   And meantime, you'd expect antiacid to help?
Doctor :   yes but the spice can cause hyper acidity which in turn trigger hernial symptoms
User :   y, i'll lay off the spice for now
User :   But let's revisit the other options then. Do my symptoms sound like they could be associated with other more serious problems (such as those I listed)? Or do they not match expectations for those (or other) serious conditions?
Doctor :   No, not at all
Doctor :   cardiac pain will be more severe and radiating to the left upper body
User :   A pulmonary embolism, for example, would have different symptoms? (That is the one I'm most concerned about because of the AF history).
Doctor :   Pulmonary embolism is an emergency and could cause immediate death
User :   correct; I have a friend who had it. My impression is that the pain is more severe.
Doctor :   Yes . thats right
User :   I assume I'd be beating a path to the emergency room as soon as I could get out the door, the pain would be severe enough.
User :   So, what about the costochondritis hypothesis? Why do you not like that one?
User :   And is there a differential treatment I could self-prescribe that would verify? for example, ibuprofen vs. antiacid.
Doctor :   Costochondritis will evolve slowly, it will not present with sudden pain
User :   slowly meaning over more than a couple hours?
Doctor :   over a couple of days
User :   ok
User :   that's not the case here
Doctor :   yes
User :   So if it is the hiatal hernia and you say it can present suddenly, what exactly is happening that is causing the pain? Is it that it tore more? (though hard to imagine just sitting on a bike) Or that it is acid?
Doctor :   its may be as a result or reverse peristalsis ( movement of food pipe and stomach ) which could have occurred due to exercise and acidity
User :   ok, that would make sense
User :   in that case, it should just disappear on its own in a day or two? or is treatment required?
Doctor :   Its self limiting , if it recurs then you may require an endoscopy
User :   ok
User :   Well, I think we are almost out of time and this has been a helpful and reassuring conversation. Thanks for the help!
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